BusinessOperations - Grievance & Appeals Coordinator I - 210056

The purpose of this team is to review, investigate and track all Medicare members and provider appeals submitted, and pursue formal resolutions for members and providers within required guidelines. Additional resources will also strengthen operational coverage, support overtime and weekend processing, and help maintain consistent productivity and quality while minimizing risks associated with staffing shortages.

Position Purpose: Analyze and resolve verbal and written claims and authorization appeals from providers and pursue resolution of formal grievances from members.

Education/Experience: High school diploma or equivalent. Associate s degree preferred. 2+ years grievance or appeals, claims or related managed care experience. Strong oral, written, and problem solving skills.

" Gather, analyze and report verbal and written member and provider complaints, grievances and appeals
" Prepare response letters for member and provider complaints, grievances and appeals
" Maintain files on individual appeals and grievances
" May coordinate the Grievance and Appeals Committee
" Support the pay-for-performance programs, including data entry, tracking, organizing, and researching information
" Assist with HEDIS production functions including data entry, calls to provider s offices, and claims research.
" Manage large volumes of documents including copying, faxing and scanning incoming mail

EEO:

Mindlance is an Equal Opportunity Employer and does not discriminate in employment on the basis of Minority/Gender/Disability/Religion/LGBTQI/Age/Veterans.

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Story Behind the Need
What is the purpose of this team? What is driving this need? (ex. Backfill for FTE or CW, new project, business growth) Describe the surrounding team (team culture, work environment, etc.) & key projects. Do you have any additional upcoming hiring needs, or is this request part of a larger hiring initiative?		The Appeals team is a collaborative, solutions-driven team focused on timely, accurate, and compliant appeals processing, inventory management, and operational excellence. The purpose of this team is to review, investigate and track all Medicare members and provider appeals submitted, and pursue formal resolutions for members and providers within required guidelines. Additional staff are needed to address increased appeal volumes, maintain compliance with regulatory timeframes, reduce inventory backlogs, and ensure timely and accurate case resolution. Additional resources will also strengthen operational coverage, support overtime and weekend processing, and help maintain consistent productivity and quality while minimizing risks associated with staffing shortages.
Typical Day in the Role
Walk me through the day-to-day responsibilities and a description of the project (Outside of the Workday JD). What are performance expectations/metrics? What makes this role unique?			Carefully evaluate all incoming appeal requests to determine the appropriate course of action, ensuring that each request is properly categorized and handled in accordance with established guidelines and procedures. Continuously track appeal timelines to ensure all deadlines are met, taking proactive measures to prevent any delays or non-compliance with required response times. Accurately compile, organize, and submit all necessary appeals documentation to C2C, ensuring that each submission is complete, timely, and adheres to the required format and procedural guidelines. Prepare response letters for members and provider appeals. validate that they are going to the correct providers/patients, and that the provider/patient demographics and reason(s) for services to be rendered are correct.
Candidate Requirements
Education/Certification	Required: High school diploma or equivalent				Preferred: Associate s degree preferred
Licensure	Required: N/A				Preferred: N/A
Years of experience required: Experience. 2+ years of grievance and appeals experience in a Healthcare or Managed Care setting. Disqualifiers: No appeals and grievance experience Additional qualities to look for:
Top 3 must-have hard skills stack-ranked by importance			1	Demonstrate strong knowledge of appeals process and work in a fast paste environment.
			2	Strong organizational and time management skills
			3	Effective problem-solving skills and ability to work independently
Candidate Review & Selection
Shortlisting process Candidate review & selection Interview information Onboard process and expectations			Projected Manager Candidate Review Date:			1-2 days post shortlisting
			Type of Interviews:			Teams On camera
			Required Testing or Assessment (by Vendor):			N/A
Next Steps